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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601032
Report Date: 10/05/2021
Date Signed: 10/05/2021 01:24:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210910153907
FACILITY NAME:EUNICE HOME IIFACILITY NUMBER:
197601032
ADMINISTRATOR:AGBEDE, SONNYFACILITY TYPE:
735
ADDRESS:17131 COURBET STREETTELEPHONE:
(818) 831-5282
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 5DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Natalia Sims/ AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Client in care sustained injury while in care
INVESTIGATION FINDINGS:
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Licensing program analyst (LPA), Patrick Shanahan, arrived at the facility in order to continue the investigation into the allegations listed above. LPA was greeted by facility staff and had his temperature taken and was led to the sink to wash his hands before being allowed into the home. The administrator arrived at the home a short while later at about 9:25 am.
Allegation 1. Client in care sustained injury while in care
On 5/18/2021 at about 8:30 PM, it was reported that the consumer in care (C1) was having behavioral issues and was attempting to pinch another resident in care. Staff redirected C1, where C1 attempted to hit the staff member. The staff member moved away from C1 in order to protect themself, and C1 hit the glass window, resulting in lacerations to C1's hand. On 10/5/21 at about 11:30 AM, the LPA was able to speak with C1's Service Coordinator regarding the incident. The service coordinator did recal the event and explained that C1 does tend to have aggressive behaviors and that Regional Center and the facility staff are working to correct these behaviors.
Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20210910153907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EUNICE HOME II
FACILITY NUMBER: 197601032
VISIT DATE: 10/05/2021
NARRATIVE
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The service coordinator did not have any concerns regarding the incident and felt that staffing was not an issue. Furthermore, the service coordinator indicated that the resident was redirected away from the other consumer and the injury occurred accidentally due to C1's behaviors. At the time of the incident, there were 5 residents and 4 staff at the facility working with the consumers. Immediately after the consumer was injured, staff called 911 and the wound was treated at a local hospital.

Based on interviews with the facility administrator, C1's service coordinator and with facility staff as well as documentation review, it is determined that the staff did do everything to prevent C1 from injuring another resident. Although C1 was injured, staffing appeared to be sufficient, therefore this allegation is deemed to be unsubstantiated.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210910153907

FACILITY NAME:EUNICE HOME IIFACILITY NUMBER:
197601032
ADMINISTRATOR:AGBEDE, SONNYFACILITY TYPE:
735
ADDRESS:17131 COURBET STREETTELEPHONE:
(818) 831-5282
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff are not following clients' behavioral plans appropriately
INVESTIGATION FINDINGS:
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Allegation 2. Staff are not following clients' behavioral plans appropriately

Licensing program analyst (LPA), Patrick Shanahan, arrived at the facility in order to continue the investigation into the allegation listed above. LPA was greeted by facility staff and had his temperature taken and was led to the sink to wash his hands before being allowed into the home. The administrator arrived at the home a short while later at about 9:25 am.

On 9/15/2021, the LPA made an initial visit to this facility inorder to gather documentation and initiate this allegation. While reviewing behavioral plans for all the residents in care, LPA observed that out of the 5 consumers in care, 3 of the residents data collection documents had not been filled out for the month of October. LPA was able to speak to the service coordinator at 11:30 AM in regards to this finding.

Continues on LIC 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20210910153907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EUNICE HOME II
FACILITY NUMBER: 197601032
VISIT DATE: 10/05/2021
NARRATIVE
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The service coordinator explained that these data collection sheets are necessary for all consumers, as this is how they gage changes and improvements for the consumers. The service coordinator continued to state, that the data collection sheet needs to be completed accurately and timely in order to make corrections if needed or to show improvements.

Based on documentation review of consumers behavioral plans, data collection sheets and interviews conducted with the administrator and the consumers service coordinator, this allegation is deemed to be substantiated at this time.

Exit interview conducted, deficiencies cited and report issued. Appeal rights discussed.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210910153907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EUNICE HOME II
FACILITY NUMBER: 197601032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
85078(a)(1)
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85078(a)(1) Responsibility for Providing Care and Supervision.
The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This requirement was not met as evidenced by:
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The administrator agrees to hold an in-service on the importance of updating the data collection sheet for all residents in care. A copy of in service sign in sheet as well as a list of topics discussed will be sent to the LPA as POC.
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The licensee did not ensure that the data collection sheet for 3 out 5 consumers was updated timely, as stated in the consumers behavioral plan, which poses an immediate risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5